Decades of neglect, a failing health system and remote mountainous topography have created a "crisis in maternal health", according to a government taskforce in Papua New Guinea.
While progress has been made since the taskforce released its recommendations in 2009, some 250 women are still dying for every 100,000 live births, according to a 2008 inter-agency estimate.
Maternal mortality rates in PNG doubled from 1996-2006, states the government's most recent national health survey, which prompted the government-appointed taskforce to find ways to make pregnancy less deadly.
Inaccessible and ill-equipped health centres, early pregnancies, poor care and ineffective communication are among the reasons health and aid workers cite for the still-high level of maternal deaths.
In PNG, the nearest health clinic might be hours by boat, foot, or in the luckiest of circumstances, local transport, from the village, says Miriam Lovai, former head of the national midwife association.
"On the Sepik River [the country's longest river] and other rivers they [women] are floated down on rafters consisting of tied banana trees or other logs," said Lovai.
At least four out of 10 people in parts of PNG cannot access healthcare due to distance or lack of roads, according to the taskforce.
Even when a woman can access trained medical care, there is still little understanding of when to seek care during childbirth, said Grace Kariwiga from the UN Children's Fund (UNICEF) office in the capital, Port Moresby. "The woman, the family or the husband, often delay seeking care, because they don't recognize the danger signals."
"Most give birth at home, because there is a lack of money, and [transport] infrastructure, so it is difficult for them to come in," said George Manapel from the national Department of Health in Goroka, the capital of East Highlands Province, one of 21 provinces.
Nationwide, 53 percent of women gave birth with a skilled birth attendant in 2006, but access to healthcare in some provinces is worse than others, noted the government taskforce.
To make it easier for pregnant women to seek care, it recommended transport subsidies.
It also suggested expanding local solutions such as a "red card" system in the remote Trobiand Islands of Milne Bay Province where women in labour can display a red card on the side of the road, which obliges any car to take her to the nearest health centre.
In a recent index of health workers' impact by the NGO Save the Children, PNG ranked in the bottom 20 of 161 surveyed countries.
Children in those countries, which all fall below the World Health Organization (WHO) minimum threshold of just over two health workers per 1,000 people, are five times more likely to die, noted the index.
PNG had one health worker (including doctors, midwives, nurses and community health workers) for every 1,000 residents in 2008, according to WHO.
Photo: Arthur Chapman
|Mountainous terrain stands between health centres and women in some parts of the country|
Even when health workers are available to serve a population growing at 2.7 percent annually, according to the most recent census in 2000, local health centres lack resources, said Lovai.
In one case Lovai tried to travel by boat to a woman five hours away who was bleeding excessively following a home birth. But the clinic did not have enough fuel, and by the time Lovai purchased some, the woman had died.
Decentralization of the health system in the 1980s, which put regional governments in charge of health budgets, has worsened access for women seeking maternal healthcare, noted the taskforce.
"The vast majority of women live in rural areas, but the rural health service is not there and is not functioning for various reasons," said Caroline Ninnes from local NGO Susu Mamas, which means Breastfeeding Mums in Pidgin, one of PNG's official languages.
"There is no support and no equipment... and supporting rural health services when access is by boat, foot, road, or even inaccessible is difficult."
Almost nine out of 10 people nationwide lived in rural areas at the time of the 2000 census, but the number of health staff in rural facilities declined by 25 percent between 1987 and 2000.
Ninnes said illiteracy made it difficult to educate women about the importance of giving birth with the assistance of a trained health worker - or waiting longer to have children.
With 800 different languages across PNG, outreach is not easy. "Languages even vary a lot between villages," said Ninnes.
Susu Mamas is calling on provincial health departments to recruit nurses from underserved communities who speak local languages in addition to the official national languages of Pidgin, Motu and English.
Almost 7 percent of women had given birth before the age of 20 in 2006, which can elevate the risk of pregnancy-related complications, according to the UN Population Fund (UNFPA).
After 27-year-old Lisa Micheals had given birth to her fifth child, she needed little persuasion to end her child-bearing days, which began at 16.
"I saw so many women die in the village, giving birth. So I got them [fallopian tubes] tied," she said.
The Health Ministry and regional health offices are trying to implement the taskforce's recommendations with support from Susu Mamas, as well as UNFPA, WHO and UNICEF, said Ninnes.
For example, the Health Ministry is trying to educate Papuans that husbands and communities should ensure safe pregnancies and deliveries.
Traditionally, pregnancy and birth have been considered a woman's domain in most of Papua's tribal societies where men and women live in separate houses. This has led to many men not understanding the dangers women face giving birth, said Lahui Geita, a government maternal health adviser.
"Pregnancy is everyone's business. It is not an issue that the mother should have to deal with alone," he said.